NCLEX Practice Questions — Set 19
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
The client who had surgery on the right elbow has no right radial pulse and the fingers are cold, the client complains of tingling, and she cannot move the fingers of the right hand. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Notify the client’s healthcare provider.
The client is exhibiting severe neurovascular compromise, which indicates a surgical complication and requires notifying the surgeon immediately.
Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) working on a surgical unit?
Show answer and rationale
Correct answer: C. Obtain vital signs on a newly admitted client.
The UAP can take vital signs on a newly admitted client.
The licensed practical nurse (LPN) is working in a surgical rehabilitation unit. Which nursing task would be most appropriate for the LPN to implement?
Show answer and rationale
Correct answer: C. Perform routine dressing changes on assigned clients.
The LPN’s scope of practice allows routine sterile procedures on the client who is stable, such as clients in a surgical rehabilitation facility.
The unlicensed assistive personnel (UAP) is changing a full sharps container in the client’s room. Which action should the nurse implement?
Show answer and rationale
Correct answer: C. Praise the UAP for taking the initiative to change the sharps container.
The nurse should reward appropriate behavior by the other healthcare members. Verbal praise is always appreciated by anyone.
The unlicensed assistive personnel (UAP) tells the nurse the client who is 5 hours postoperative for an L-3/L-4 laminectomy is complaining of feeling numbness in both feet. Which intervention should the nurse implement?
Show answer and rationale
Correct answer: A. Complete the neurovascular assessment on the client’s legs.
The nurse should assess the client whenever receiving any information from another member of the healthcare team.
The ED nurse is requesting a bed in the intensive care unit (ICU). The ICU charge nurse must request a transfer of one client from the ICU to the surgical unit to make room for the client coming into the ICU from the ED. Which client should the ICU charge nurse request to transfer to the surgical unit?
Show answer and rationale
Correct answer: D. The client who is 1 day postoperative for total hip replacement (THR) whose incisional dressing is dry and intact.
Although the client is only 1 day postoperative for a total hip replacement, it is an elective procedure, which indicates that the client was stable prior to the surgery. The incision is also dry and intact. Of the four clients, this client is the most stable and should be transferred to the surgical unit.
A terrible storm causes the electricity to go out in the hospital and the emergency generator lights come on. Which action should the charge nurse implement?
Show answer and rationale
Correct answer: A. Instruct the staff to plug critical electrical equipment into the red outlets.
During an electrical failure, the red outlets in the hospital run on the backup generator, and all IV pumps and necessary equipment should be plugged into these outlets.
The HCP is angry and yelling in the nurse’s station because the client’s laboratory data are not available. Which action should the charge nurse implement first?
Show answer and rationale
Correct answer: A. Ask the HCP to step into the nurse’s office.
This is the charge nurse’s first action because it will diffuse the HCP’s anger. Inappropriate behavior at the nurse’s station should not occur in an area where visitors, clients, or staff will observe the behavior.
The staff nurse is concerned about possible increasing infection rates among clients with peripherally inserted central catheters (PICCs). The nurse has noticed several clients with problems in the last few months. Which action would be appropriate for the staff nurse to implement first?
Show answer and rationale
Correct answer: D. Contact the infection control nurse to discuss the problem.
Possibly increasing infection rates among clients with PICCs falls within the infection control nurse’s scope of practice, and the infection control nursing staff will have data from all units in the hospital.
The charge nurse on the 30-bed surgical unit has been told to send one staff member to the medical unit. The surgical unit is full, with multiple clients who require custodial care. Which staff member would be most appropriate to send to the medical unit?
Show answer and rationale
Correct answer: C. Send the licensed practical nurse (LPN) who has 3 years of experience, which includes 6 months on the medical unit.
The LPN would be the most appropriate staff to send to the medical unit because the LPN has experience on the unit. His or her expertise is also not required to perform custodial care.
The client tells the nurse, "I am having surgery on my right knee." However, the operative permit is for surgery on the left knee. Which action should the nurse implement first?
Show answer and rationale
Correct answer: D. Initiate the time-out procedure.
According to the Joint Commission, the first intervention is to call a time-out, which stops the surgery until clarification is obtained.
The older adult client fell and fractured her left femur. The nurse finds the client crying, and she tells the nurse, "I don’t want to go to the nursing home but my son says I have to." Which response would be most appropriate by the nurse?
Show answer and rationale
Correct answer: A. "I can see you are upset. Would you like to talk about it?"
According to the NCLEX-RN� test plan, advocacy is part of Management of Care under Safe and Effective Care Environment client needs. Therapeutic communication involves being an advocate in this situation, because sometimes the nurse cannot prevent a perceived "bad" situation from occurring.
The client is confused and pulling at the IV and indwelling catheter. Which order from the HCP should the nurse clarify concerning restraining the client?
Show answer and rationale
Correct answer: A. Restrain the client’s wrists, as needed.
The client cannot be restrained as needed. The nurse must have documentation for the need and an HCP’s specific order that includes reason for restraint and time limited to no more than 24 hours. This HCP order should be clarified.
The charge nurse on a 20-bed surgical unit has one RN, two licensed practical nurses (LPNs), and two unlicensed assistive personnel (UAPs) for a 12-hour shift. Which task would be an inappropriate delegation of assignments?
Show answer and rationale
Correct answer: A. The LPN should administer all IVP medications.
The LPN may be allowed administer some IVP medications in some facilities, but the word "all" makes this an inappropriate assignment. Many IVP medications are considered high risk, and only RNs should administer such IVP medications.
The head nurse is completing the yearly performance evaluation on a nurse. Which data regarding the nurse’s performance should be included in the evaluation?
Show answer and rationale
Correct answer: A. The chart audits of the clients for whom the nurse cared.
The nurse’s ability to document client care directly correlates with the nurse’s performance; therefore, these data should be included in the yearly evaluation.
The nurse is discharging the 72-year-old client who is 5 days postoperative for repair of a fractured hip with comorbid medical conditions. At this time, which referral would be the most appropriate for the nurse to make for this client?
Show answer and rationale
Correct answer: D. To a rehabilitation facility.
The rehabilitation facility will provide intensive therapy and address the comorbid conditions 24 hours a day. This will assist in the client’s recovery.
The nurse is caring for clients on a 12-bed intermediate care surgical unit. Which task should the nurse implement first?
Show answer and rationale
Correct answer: C. Complete the preoperative checklist for the client scheduled for surgery.
The client scheduled for surgery is priority and must be ready when the OR calls; therefore, completing the preoperative checklist is the first task the nurse should implement. The preoperative checklist ensures the client’s safety.
The nurse is preparing to administer medications to clients on a surgical unit. Which medication should the nurse question administering?
Show answer and rationale
Correct answer: A. The antiplatelet clopidogrel (Plavix) to a client scheduled for surgery.
Antiplatelet medication will increase the client’s bleeding time and should be held 5 days prior to surgery; therefore, this medication should be questioned.
The nurse is caring for clients on a surgical intensive care unit. Which client should the nurse assess first?
Show answer and rationale
Correct answer: D. The client who is 12 hours postoperative for total knee replacement (TKR) who is complaining of numbness and tingling in the foot.
The client is exhibiting signs of compromised circulation; therefore, the nurse should assess this client first. The nurse should assess for the 6 Ps: pain, pulse, paresthesia, paralysis, pallor, and polar (cold).
Which situation should the charge nurse in the critical care unit address first after receiving the shift report?
Show answer and rationale
Correct answer: A. Talk to the family member who is irate over his loved one’s nursing care.
This situation should be addressed first because the charge nurse is responsible for family/client complaints. If the family contacts the administration, the charge nurse must be aware of the situation.
The nurse in the critical care unit of a medical center answers the phone and the person says, "There is a bomb in the hospital kitchen." Which action should the nurse take?
Show answer and rationale
Correct answer: D. Notify the hospital security department.
The chain of command in a hospital is to notify the security department, and they will institute the hospital procedure for the bomb threat.
The critical care unit is having problems with staff members clocking in late and clocking out early from the shift. Which statement by the charge nurse indicates he has a democratic leadership style?
Show answer and rationale
Correct answer: C. "We are going to have a meeting to discuss the clocking in procedure."
A democratic manager is people oriented and emphasizes efficient group functioning. The environment is open and communication flows both ways, and this includes having meetings to discuss concerns.
Which client should the charge nurse of a long-term care facility see first after receiving shift report?
Show answer and rationale
Correct answer: A. The client who is upset because the call light was not answered for 30 minutes.
This client may or may not have a valid complaint. The nurse should investigate whether or not the complaint is true. Failure to answer a call light can result in the client’s attempting to ambulate without assistance and could be a safety issue. The nurse should speak with this client first.
The male client in a long-term care facility complains that the staff does not listen to his complaints unless a family member also complains. Which action should the director of nurses implement?
Show answer and rationale
Correct answer: A. Talk with the resident about his concerns and then initiate a plan of action.
The director of nurses should discuss the resident’s complaints with the resident and then determine a plan of action to remedy the situation.
The newly admitted client in a long-term care facility stays in the room and refuses to participate in client activities. Which statement is a priority for the nurse to discuss with the client?
Show answer and rationale
Correct answer: B. "You seem sad; would you like to talk about how you are feeling about being here?"
This client is exhibiting symptoms of depression. Therapeutic conversation is implemented to help the client vent feelings. This statement acknowledges the client’s feeling and offers help.
The charge nurse overhears two unlicensed assistive personnel (UAPs) discussing a client in the hallway. Which action should the charge nurse implement first?
Show answer and rationale
Correct answer: A. Remind the UAPs that clients should not be discussed in a public area.
The charge nurse should remind the UAPs not to discuss confidential information in a public place. This is the first action.
The family member of a client in a long-term care facility is unhappy with the care being provided for the loved one. Which person would be most appropriate to investigate the complaint and report the findings during a client care conference?
Show answer and rationale
Correct answer: A. The ombudsperson for the facility.
An ombudsman is a representative appointed to receive and investigate complaints made by individuals of abuses or capricious acts. All Medicare and Medicaid long-term care facilities must have an ombudsman to act as a neutral party in matters of dispute with the facility. This is the best person to investigate a complaint.
The 65-year-old client is being discharged from the hospital following major abdominal surgery and is unable to drive. Which referral should the nurse make to ensure continuity of care?
Show answer and rationale
Correct answer: D. A home health agency.
The nurse should refer the client to a home health agency for follow-up care. The nurse will go to the client’s home to assess the client and perform dressing changes. The home health agency will also assess the client and the client’s home for further needs.
The nurse in an assisted living facility notes that the male client has several new bruises on both of his arms and hands. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Ask the client whether he has fallen and hurt himself during the night.
The nurse should ask the client whether there is a reason for the bruises that the nurse should be aware of. This is the first intervention and can be done while the nurse is currently with the client.
The resident in a long-term care facility tells the nurse, "I think my family just put me here to die because they think I am too much trouble." Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: B. "Can you tell me more about how you feel since your family placed you here?"
The client is expressing negative feelings about being placed in the nursing home. Asking about the client’s feelings is a therapeutic response that encourages the client to discuss his or her feelings.
The admitting nurse is subpoenaed to give testimony in a case in which the client fell from the bed and fractured the left hip. The nurse initiated fall precautions on admission but was not on duty when the client fell. Which issue should the nurse be prepared to testify about the incident?
Show answer and rationale
Correct answer: C. The facility’s policy covering falls prevention.
The nurse initiated a policy that is designed to prevent falls from occurring. This is all the nurse can testify to.
The charge nurse must notify a staff member to stay home because of low census. The unit currently has 35 clients who all have at least one IV and multiple IV medications. The unit is staffed with two RNs, three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which nurse should be notified to stay home?
Show answer and rationale
Correct answer: D. The UAP who asked to be requested off.
The UAP cannot administer medications or IVs and has requested to be allowed to stay home. This is the best staff member to request to stay home.
The charge nurse in an extended care facility notes an elderly male resident holding hands with an elderly female resident. Which intervention should the charge nurse implement?
Show answer and rationale
Correct answer: D. Do nothing, because this is a natural human need.
The charge nurse does not have a right to interfere with two consenting adults having a relationship. Doing nothing is the correct action for the charge nurse. If one of the residents involved is incapable of giving consent to a relationship, then the charge nurse would need to get involved.
The chief nursing officer (CNO) of an extended care facility is attending shift report with two charge nurses, and an argument about a resident’s care ensues. Which action should the CNO implement first?
Show answer and rationale
Correct answer: D. Listen to both sides of the argument and then implement a plan of care.
The CNO should evaluate the concerns of each charge nurse and then make a decision as to a plan of care for the resident. The CNO is the next in command over the charge nurses in an extended care facility.
Which action by the nurse is a violation of the Joint Commission’s Patient Safety Goals?
Show answer and rationale
Correct answer: D. The nurse educator gives the orientee the answers to the quiz covering the IV pumps.
A quiz during orientation is given to assess whether the new employee understands the information being taught. Giving the answers to the quiz completes the required documentation for the employee’s files but does not ensure the new hire understands how to utilize the IV pump. This is a violation of the Patient Safety Goals.
The community health nurse is triaging victims at a bus accident. Which client would the nurse categorize as red, priority 1?
Show answer and rationale
Correct answer: C. The client with compound fractures of the tibia and fibula.
This client should be categorized as red, priority 1, which means the injury is life threatening but survivable with minimal intervention. These clients can deteriorate rapidly without treatment.
The clinic nurse is reviewing the laboratory data of clients seen in the clinic the previous day. Which client requires immediate intervention by the nurse?
Show answer and rationale
Correct answer: B. The client whose International Normalized Ratio (INR) is 3.8.
The therapeutic range for an INR is 2 to 3.This client is at risk for bleeding and requires immediate intervention by the nurse. The nurse should call the client and instruct the client to stop taking warfarin (Coumadin), an anticoagulant.
The community health nurse is triaging victims at the scene of a building collapse. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Place disaster tags securely on the victims.
Client tracking is a critical component of casualty management. Disaster tags, which include name, address, age, location, description of injuries, and treatments or medications administered, must be securely attached to the client.
Which statement best describes the role of the parish nurse?
Show answer and rationale
Correct answer: B. The parish nurse practices holistic healthcare within a faith community.
Parish nursing emphasizes the relationship between spiritual faith and health. A parish nurse (PN) is a registered nurse with a minimum of 2 years’ experience who works in a faith community to address health issues of its members as well as those in the broader community or neighborhood.
The HH aide calls the HH nurse to report that the client has a reddened area on the sacral area. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: C. Visit the client to assess the reddened area.
The nurse must first assess the reddened area to determine the stage of the pressure ulcer and what treatment should be recommended.
The 32-year-old male client with a traumatic right above-the-elbow amputation tells the home health (HH) nurse he is worried about supporting his family and finding employment since he can’t be a mechanic anymore. Which intervention should the nurse implement?
Show answer and rationale
Correct answer: C. Refer the client to the state rehabilitation commission.
The NCLEX-RN� test blueprint lists referrals under Management of Care. After a client has been injured and is unable to return to previous employment because of the injury, the rehabilitation commission of each state will help evaluate the client and determine whether the client is eligible to receive training or education for another occupation.
The labor and delivery nurse has assisted in the delivery of a 37-week fetal demise. Which intervention should the nurse implement?
Show answer and rationale
Correct answer: B. Remove the baby from the delivery area quickly.
The mother may want to see her infant before the body is removed from the room.
The newborn nursery nurse has received report. Which client should the nurse assess first?
Show answer and rationale
Correct answer: D. The 2-hour-old infant who has nasal flaring and is grunting.
Nasal flaring and grunting indicate the infant is in respiratory distress. The nurse should assess this infant first.
The psychiatric clinic nurse is returning telephone calls. Which telephone call should the nurse return first?
Show answer and rationale
Correct answer: D. The male client who reports he is tired of living, since his wife just left him because he lost his job.
The nurse should return this call first because the nurse must determine whether the client has a plan for suicide.
The psychiatric nurse and mental health worker (MHW) on a psychiatric unit are caring for a group of clients. Which nursing task should the nurse delegate to the MHW?
Show answer and rationale
Correct answer: C. Take the school-aged children to the on-campus classroom.
Pediatric clients in a psychiatric facility must keep up with schoolwork. Clients must be escorted from one building to another. The MHW should be assigned to this task.
The 36-year-old client in the women’s health clinic is being prescribed birth control pills. Which information is important for the nurse to teach the client? Select all that apply.
Show answer and rationale
Correct answer: A. Take one pill at the same time every day.
The client should take the pill at approximately the same time each day to maintain a blood level of the hormone.
The nurse is caring for a female client 3 days post-knee replacement surgery when the client complains of vaginal itching. The medication administration report (MAR) indicates the client has been receiving the antacid calcium carbonate (Maalox), the antibiotic ceftriaxone (Rocephin), and the anticoagulant enoxaparin (Lovenox). Which priority intervention should the nurse implement?
Show answer and rationale
Correct answer: C. Explain to the client this is the result of the antibiotic therapy.
The nurse should first explain to the client that this is a side effect of the antibiotic medication. Then, the nurse should notify the dietitian and HCP. The antibiotic therapy cannot be discontinued because of the need for antibiotic therapy after knee replacement surgery.
The nurse manager of the maternal-child department is developing the budget for the next fiscal year. Which statement best explains the first step of the budgetary process?
Show answer and rationale
Correct answer: C. Ask the staff for input about needed equipment.
The manager should ask for input into the budgetary needs from the staff, but an assessment of the current year’s budget is the first step.
Which of the following nursing activities should the registered nurse delegate to a licensed practical nurse?
Show answer and rationale
Correct answer: D. Monitor the vital signs of a client with cellulitis for evidence of sepsis
A licensed practical nurse may not instruct, develop a teaching plan, or obtain a health history. Those are activities reserved for the registered nurse. A licensed practical nurse may monitor the vital signs of a client with cellulitis for evidence of sepsis. A licensed practical nurse is trained to monitor vital signs for deviations from normal and then report those changes to a registered nurse.
Which of the following is a priority to include when instructing a client to perform a skin assessment?
Show answer and rationale
Correct answer: A. "Assess the entire body and look for changes in skin or moles."
Skin self-examination includes the entire body, looking for any changes in skin color as well as changes in moles. Although evaluating the evenness of skin color, moisture, and temperature is an appropriate intervention, it�is�limited in its focus to two insignificant characteristics of skin moisture and temperature. These do not change with development of skin cancer. Inspecting moles is also an important part of a skin examination, but limits the skin assessment to moles only and negates the rest of the assessment. Performing a skin examination is an ongoing assessment and not just something that begins after age 40.
The nurse assesses a client’s skin and finds an elevated, solid lesion on the client’s great toe. It is pink, nontender, and 0.5 cm in size. Which of the following is the most appropriate action by the nurse?
Show answer and rationale
Correct answer: A. Gather more information about the lesion from the client
More information is needed about the lesion to help determine an appropriate course of action. The findings do not require immediate attention from the physician. It is inappropriate to determine a plan of action without completing a thorough assessment. Determining what the client has been doing to treat the lesion only gathers part of the data needed to determine a plan of action.
The nurse instructs a client with pruritus to apply an emollient immediately after bathing. The nurse understands that the rationale for this intervention is to
Show answer and rationale
Correct answer: A. prevent evaporation of water from the epidermis.
Emollients seal in water and hydrate the skin.�Emollients do not affect the blood vessels. The emollient is not in contact with the subcutaneous tissue. The primary function of an emollient is to rehydrate the skin. Intact skin is the best defense against irritation.
The nurse is discharging a client who developed a skin tear while hospitalized for surgery. The nurse instructs the client in wound care for the skin tear. Which of the following would be essential to include in the wound care instructions for this client?
Show answer and rationale
Correct answer: A. Use a nonadherent dressing over the wound
Use of a nonadherent dressing is the most helpful in treatment of skin tears. A transparent dressing causes maceration of the skin and may cause further skin trauma with removal. A diet high in fat does not help with healing. A diet high in protein and vitamin C is more likely to help healing. The primary treatment of skin tears is protecting them from further trauma so they can heal.
The nurse is teaching a mother about caring for her 4-year-old with atopic dermatitis. Which of the following statements by the mother indicates that the teaching has been successful?
Show answer and rationale
Correct answer: B. "I will avoid using fabric softeners in the laundry."
Fabric softeners often contain chemicals or components that are irritants for those with atopic dermatitis. Dermatitis is not a contagious condition, so using separate towels is not necessary. Avoidance of certain foods in treating atopic dermatitis is controversial. It is recommended that only known allergens be avoided. The sun is not a trigger for atopic dermatitis.
The nurse is teaching a class on the treatment of psoriasis with methotrexate. Which of the following should the nurse include in her teaching?
Show answer and rationale
Correct answer: D. An effective birth control for both men and women must be taken
Because methotrexate is associated with chromosomal abnormalities, both men and women must use highly effective birth control during therapy. Methotrexate may be used in clients with very severe disease who have been unresponsive to other therapies, regardless of age. The appropriate lab work to monitor when a client is taking methotrexate includes blood chemistry and liver and renal function studies. Methotrexate is only used when all other treatment options fail.
The nurse is evaluating the following four clients for the development of a pressure ulcer. Which of the following clients is at greatest risk for the development of a pressure ulcer?
Show answer and rationale
Correct answer: A. A 74-year-old thin male, who is awaiting surgery for a fractured left hip
Risk factors for the development of pressure sores include bony prominences, inability to change position independently, and a bed-rest status. These factors pose the highest risk for the client.
The nurse is instructing a client with herpes zoster on self-care. Which of the following statements by the client indicates the teaching has been successful?
Show answer and rationale
Correct answer: C. "I will stay away from my young grandchildren."
People who have not had chickenpox may get it from exposure to those with herpes zoster. Cool baths, although soothing, do not speed up the healing process. Topical diphenhydramine is useful for itching but will not accelerate the healing process. The use of fabric softener is unrelated to herpes zoster.
When assessing for changes in skin color in an African-American client, the nurse should assess which of the following first?
Show answer and rationale
Correct answer: B. Nail beds or oral mucosa
Assessment of the skin of those with naturally darker pigmentation should be done in an area where the epidermis is thin or in areas of least pigmentation, such as the nail beds or oral mucosa. The soles of the feet and palms of the hands are the second best options. It would not be appropriate to inspect the conjunctiva or sclera of an African-American client for skin color because of the possibility of yellowing.
The nurse is preparing to teach a class on the prevention of skin problems. Which of the following is a priority for the nurse to instruct clients to avoid?
Show answer and rationale
Correct answer: C. Sunlight
Limiting exposure to the sun is the most important preventive measure in reducing the risk of developing skin cancer and premature aging. Radiation and alkaline soaps are less common causes of skin problems. Overexposure to vitamin E does not cause skin problems.
The nurse is caring for a client during the emergent phase of a burn injury. Which of the following assessments would provide the nursewith the most accurate information regarding this client’s full-thickness burns?
Show answer and rationale
Correct answer: B. Leathery, dry, hard skin
A burn that has leathery, dry, and hard skin describes a full-thickness burn in the emergent phase. A burn that is a red, fluid-filled vesicle with massive edema at the injury site describes a deep partial-thickness burn during the emergent phase. Serous exudate from a shiny, dark-brown wound describes a partialthickness burn in the acute phase.
Using an open method of skin care, which of the following should the nurse include when caring for a client with deep partial-thickness burns of both legs?
Show answer and rationale
Correct answer: C. Apply topical silver sulfadiazine (Silvadene) with clean gloves
The open method requires cleansing the wounds, applying a topical antimicrobial, and leaving the wounds open to air. Either saline or an electrolyte solution is best to use in the debridement tank. It would be inappropriate to use the open method with a partial-thickness burn because there are no dressings in place.
The nurse notifies the physician that a client who is 12 hours postburn has abdominal distention and faint, intermittent bowel sounds. Which of the following should the nurse perform?
Show answer and rationale
Correct answer: B. Insert a nasogastric tube
Paralytic ileus is common in the postburn phase and is best treated with a nasogastric tube to suction for decompression. All oral intake should be withheld. Administering a histamine-blocking medication will not improve peristalsis, although it may be given to reduce the possibility of aspirating acidic stomach contents. It would not be appropriate to prepare the client at this time for administration of an enema. Once there is evidence of peristalsis (bowel sounds are present, the client passes flatus), an enema may be administered.
The nurse is caring for a client with a burn injury who has a nursing diagnosis of impaired physical mobility related to limited range of motion secondary to pain. Which of the following is the priority nursing intervention for this client?
Show answer and rationale
Correct answer: D. Provide an analgesic medication before physical activity and exercise
Control of pain is crucial before clients will participate in their prescribed exercise routine. This is best facilitated by administering an analgesic medication before physical activity. Controlling the pain should be followed by encouraging range of motion and instructing the client on the importance of exercise to prevent contractures. Arranging for a client to see a physical therapist does not address pain control. In fact, most burn patients find hydrotherapy to be very painful because of the debridement that must occur at that time.
Which of the following statements by a client who received instructions on pain control prior to a dressing change indicates the instructions were understood?
Show answer and rationale
Correct answer: A. "I will ask the nurse for IV morphine 5�minutes before my dressing change."
Pain control in a burn injury includes administering IV morphine just prior to the dressing change. Midazolam (Versed) is a good drug for pain control but it must be administered too far in advance to be of maximal benefit. Acetaminophen (Tylenol) is not an adequate analgesic for pain associated with full-thickness burns. Listening to music may be a good adjunct therapy to medication to control pain prior to a dressing change for a burn, but it is usually not enough by itself to control a client’s pain.
The client who has burns on the face, neck, and chest asks why a pressure garment must be worn so many hours a day prior to dressing changes. Which of the following statements by the nurse provides the most accurate explanation?
Show answer and rationale
Correct answer: B. "It reduces the thickness of the scar tissue."
Pressure garments flatten scar tissue, giving the client more mobility and resulting in a better cosmetic appearance. Wearing a pressure dressing does protect the site from further injury, but this is not the major reason for wearing a pressure garment. Wearing a pressure dressing does not support or splint the body part, nor does it trap the oils in the skin.
The nurse is planning to debride and remove scales and crusts of skin lesions to the left leg of a client. Which of the following is a priority intervention for this client?
Show answer and rationale
Correct answer: B. Warm saline dressings
Debridement is best accomplished using a warm solution. Saline is the best choice. A cool oatmeal or sodium bicarbonate bath is best used for pruritus. Magnesium sulfate will not be helpful for the person with scaly and crusty skin.
A client with chronic skin lesions on the face and arms admits to the nurse of being unable to look in the mirror. Based on this information, which of the following nursing diagnoses would the nurse identify?
Show answer and rationale
Correct answer: C. Disturbed body image related to perception of unsightly lesions
Defining characteristics for disturbed body image include verbalization of self-disgust and inability to look at oneself in the mirror. Anxiety would be an appropriate nursing diagnosis only if the client verbalizes or demonstrates anxiety related to appearance. Social isolation or deficient knowledge would be an appropriate diagnosis only if the client verbalizes these as problems.
The nurse is caring for a client with fullthickness burns who is receiving fluid replacement. Which of the following would indicate to the nurse that the client’s condition is deteriorating?
Show answer and rationale
Correct answer: A. Systolic blood pressure (BP) of 86
A decrease in the systolic blood pressure to less than 90�mm Hg indicates evaporation, plasma loss, and a fluid shift into the interstitium secondary to the burn injury. A urinary output of between 30 and 50 ml per hour, respiration rate of 18, and a pulse rate of 85 are all considered normal.
A client with burns over the face, arms, and trunk is requesting pain medication. When intervening in this situation, the nurse should administer which of the following drugs of choice for pain control in burn management?
Show answer and rationale
Correct answer: A. Morphine
Morphine sulfate is the drug of choice in the treatment of burns. Meperidine (Demerol) may also be used but is not the drug of choice. Oxycodone/aspirin (Percodan) and propoxyphene/ acetaminophen (Darvocet) are not strong enough drugs to provide adequate pain relief.
In planning the care for a severely burned client, the nurse should select which of the following as the priority nursing diagnosis?
Show answer and rationale
Correct answer: D. Risk for deficient fluid volume related to a fluid shift, evaporation, and plasma loss
The priority nursing diagnosis for a client with burns is risk for deficient fluid volume related to a fluid shift, evaporation, and plasma loss.
The nurse implements which of the following nursing measures as preventing dilutional hyponatremia in a client with burns?
Show answer and rationale
Correct answer: D. Encourage the client to drink fluids other than water
The client is encouraged to drink fluids other than water as a means of preventing dilutional hyponatremia, also known as water intoxication. Fluids rich in electrolytes and calories are offered.
Which of the following nursing interventions should the nurse include in the rehabilitative phase of burn care?
Show answer and rationale
Correct answer: D. Administer range-of-motion exercises
Administering range-of-motion exercises is an appropriate intervention for the rehabilitative phase of burn care. Establishing and maintaining a patent airway, inserting two large-bore catheters percutaneously, and using the Parkland formula to calculate fluid requirement are interventions reserved for the emergent and acute phase of burn management.
Which of the following nursing tasks should the nurse delegate to unlicensed assistive personnel?
Show answer and rationale
Correct answer: A. Assist with bathing of a client with a burn
Removing a dressing, providing client instruction, and encouraging a client to verbalize feelings are all activities that require the skills of a qualified nurse. Although socialization is a skill that unlicensed assistive personnel may perform, encouraging a client to verbalize feelings is a skill that requires the expertise of the nurse in assisting the client to deal with the expressed feelings. Unlicensed assistive personnel may assist with the bathing of a client who sustained a burn.
The nurse is caring for a client who just returned from surgery with a long leg cast. Which of the following interventions is the priority in the first 24 hours?
Show answer and rationale
Correct answer: D. Elevate the leg on a pillow above heart level
The priority nursing intervention for a client with a long leg cast in the first 24 hours is to elevate the extremity above the level of the heart by placing the leg on several pillows to prevent edema. The edges of the cast may be checked for smoothness or roughness.
Immediately after application of a plaster of paris cast, the client asks the nurse when weight bearing may begin. The most appropriate response by the nurse is which of the following?
Show answer and rationale
Correct answer: A. "Generally after 24 to 48 hours."
Generally for 24 to 48 hours after direct cast application, direct weight bearing is contraindicated. After the 24- to 48-hour time frame, a walking heel will be applied to the cast.
The client asks the nurse after a total hip replacement with a cemented prosthesis when ambulation and weight bearing may begin. The nurse bases the answer on the knowledge that weight bearing and ambulation
Show answer and rationale
Correct answer: C. may begin with a walker the first postoperative day.
Weight bearing and ambulation following a total hip replacement with a cementedprosthesis may begin with a walker the first postoperative day.
The nurse is caring for a client who has a compression dressing in place after an amputation. The nurse appropriately removes the dressing
Show answer and rationale
Correct answer: C. for bathing and physical therapy.
The compression dressing that is applied immediately following surgery is only removed for bathing and physical therapy. The purpose of the compression dressing is to support the soft tissues while reducing edema and promoting limb shrinkage to ensure a good prosthetic fit at a later date.
The nurse is discharging a client with rheumatoid arthritis who complains of morning stiffness. Which of the following measures should the nurse include in the discharge instructions?
Show answer and rationale
Correct answer: C. Instruct the client to take a warm shower in the morning when getting up
Morning stiffness is a common complaint of clients with rheumatoid arthritis because of the limited joint movements. A warm shower upon arising is recommended to increase mobility and decrease discomfort associated with the limited mobility. Cold packs may be used during exacerbations of the disease, but heat is most effective to relieve stiffness. The work of cleaning the house should be spread out throughout the week and not done at one time.
Before a client has skin traction applied, which of the following should the nurse include in the instructions given to the client?
Show answer and rationale
Correct answer: A. Skin traction is applied until surgery can be performed
The purpose of skin traction such as Buck’s, Bryant’s, Russell, a pelvic belt, or a sling is simply to stabilize the affected part and maintain alignment until surgery or skeletal traction can be performed. Skin traction is only a short-term treatment and generally for no longer than 48 to 72 hours. Generally the weight for skin traction does not exceed 7 to 10�pounds.
In planning the post-op care for a client with a hip spica cast, the nurse should know that the best method of positioning this client would be to
Show answer and rationale
Correct answer: B. turn the client side to side and support with pillows.
A client with a hip spica cast should be turned from side to side and supported with pillows. The prone position and turning the client by using the support bar are contraindicated because they can cause the cast to break.
Which of the following dietary guidelines should the nurse provide to a client with a fracture?
Show answer and rationale
Correct answer: B. High-fiber foods and 2000 to 3000 ml of fluids daily
Although three well-balanced meals are encouraged following a fracture, an excessive calorie intake is to be avoided because of the limited mobility that predisposes the client to weight gain. A high-fiber diet and increased fluid intake are necessary to prevent constipation. Adequate protein and calcium intake must be maintained to ensure adequate healing.
Which of the following changes in a client’s neurovascular assessment should be reported as a critical sign of arterial insufficiency?
Show answer and rationale
Correct answer: B. Pale extremity that is cool to touch
A pale and cool extremity following a musculoskeletal injury is the classic indication of arterial insufficiency and must be immediately reported. Hypersensation below the injury as well as other abnormal sensations may be experienced, but they are not the priority finding. An evaluation of a potential problem including a comparison of the affected and unaffected extremity will prove beneficial. Pain unrelieved by analgesics is indicative of compartment syndrome. Reduced movement in the affected extremity should be investigated as potential damage to the motor component of the affected nerves.
In planning the postoperative care for a client with a cast, the nurse would select which of the following as an appropriate nursing diagnosis?
Show answer and rationale
Correct answer: B. Constipation related to decreased mobility
Constipation related to decreased mobility is an appropriate nursing diagnosis for a client with a cast.
Which of the following interventions would be appropriate for the nurse to include in the treatment plan of a client with a stump?
Show answer and rationale
Correct answer: A. Expose the stump to air for 20 minutes
Following an amputation, the stump is exposed to air for 20 minutes daily after washing to promote adequate drying. Lotion and alcohol are contraindicated unless specifically prescribed by the physician. Scrubbing a stump is strictly contraindicated. The stump should be gently cleansed.
The nurse is assisting a client to walk with a crutch for the first time after an amputation. Which of the following indicates the nurse correctly understands the principles of crutch walking after an amputation?
Show answer and rationale
Correct answer: B. Assist the client to crutch walk for no more than 5 minutes
Initially following an amputation, crutch walking is limited to 5 minutes to avoid dependent edema. A client should never place weight on the axilla. This can compromise the nerve passing through the axilla. A compression dressing would not be removed prior to ambulation. Administration of an analgesic 30 minutes prior to ambulation could cause sedation and predispose a client to a fall.
Because a client has bursitis, plans for nursing interventions should include
Show answer and rationale
Correct answer: D. rest.
Bursitis is inflammation of the bursa (small sacs of the connective tissues lined with synovial fluid). Bursitis is generally the result of some kind of mechanical injury and is most successfully treated by rest.
The nurse is admitting a client with rheumatoid arthritis. Which of the following laboratory test results would the nurse evaluate as being elevated and used to monitor disease activity?
Show answer and rationale
Correct answer: D. Erythrocyte sedimentation rate
Although no single laboratory test is used for rheumatoid arthritis, the erythrocyte sedimentation rate (ERS) is elevated in over 80% of clients and is used to monitor disease activity and the response to treatment.
The nurse assists a client with osteoporosis to make which of the following menu selections?
Show answer and rationale
Correct answer: C. Sardines and cooked broccoli
Osteoporosis is characterized by a deterioration of bone and increased bone fragility. An adequate intake of calcium is essential in both the prevention and treatment of osteoporosis. Foods high in calcium include milk and milk products, sardines, salmon, and certain green leafy vegetables such as broccoli. Eggs, fruits, poultry, and potatoes are poor calcium food choices.
The nurse expects to find which of the characteristic clinical manifestations in a client with osteoarthritis?
Show answer and rationale
Correct answer: C. Joint pain that is relieved by rest
Joint pain that is relieved by rest is characteristic of osteoarthritis. Pain and stiffness are made worse with increased humidity and a low barometric pressure. Heberden’s nodes are bony overgrowths at the distal interphalangeal joints. Bouchard’s nodes involve the proximal interphalangeal joints. Although these nodes are generally red, swollen, and tender, they do not cause a significant loss of function.
The nurse is admitting a client for possible systemic lupus erythematosus (SLE). When assessing this client, the nurse understands that the most significant clinical manifestation present in SLE is
Show answer and rationale
Correct answer: C. discoid rash over the face and upper chest.
A discoid (coinlike) rash is the classic dermatologic manifestation of systemic lupus erythematosus. It characteristically takes on a butterfly appearance.
The nurse is caring for a client with an open fracture. Which of the following would be the priority to include in this client’s treatment plan?
Show answer and rationale
Correct answer: D. Tetanus toxoid
The priority nursing intervention for an open fracture in which the skin integrity is broken is to administer a tetanus toxoid. A high-protein diet would be important but not the priority.
A client is scheduled for an open reduction internal fixation (ORIF) of a fracture. The nurse is explaining to the client why this procedure is necessary. Which of the following is the primary reason for the nurse to give a client that best describes the purpose of the ORIF?
Show answer and rationale
Correct answer: D. "It is necessary when no other realignment method can be completed."
When no other method, such as long-term immobility, can accomplish realignment for a fracture, open reduction internal fixation (ORIF) will be completed. Pain is evident in a fracture; however, with the medications available today, pain can usually be controlled enough to complete a closed reduction either under IV conscious sedation or with general anesthesia.
A client with a fractured pelvis has a nursing diagnosis of impaired mobility related to bed rest, weakness, and traction. The nurse should inform the client that the rationale for maintaining good body alignment in the bed is to
Show answer and rationale
Correct answer: B. reduce musculoskeletal strain and enhance lung expansion.
Fractures cause damage to the affected bone, placing additional strain on the surrounding tissues, ligaments, and joints. Traction places the affected bone in proper alignment to reduce the strain on the surrounding parts. A client who has bed rest ordered may have a rapid deconditioning resulting in decreased lung capacity and orthostatic hypotension. Proper body alignment reduces the strain and increases lung expansion.
The nurse has given discharge instructions to a client with an above-the-knee amputation who will be fitted with a prosthesis when healing is complete. Which of the following statements by the client would indicate that the client has understood the instructions?
Show answer and rationale
Correct answer: C. "I should lie on my abdomen for 30 minutes three or four times a day."
Lying on the abdomen will help to make a wellrounded stump and prevent hip contractures. The limb sock should always be changed daily. Lotion is never used on a stump. Elevation is not a treatment of amputation. Pressure on the stump and hip contractures are to be avoided.
The nurse assesses that a client has lower-extremity weakness on the left. What should the nurse observe the client doing to evaluate the client’s ability to use a walker?
Show answer and rationale
Correct answer: C. Moving both the walker and the left leg forward 12 inches, then moving the right leg while the body weight is supported by the arms and the left leg
A walker is a mechanical aid used for walking assistance by clients who need more support than a cane. Instructions for use of a walker are to move the walker and affected leg ahead 6 inches, then move the stronger leg ahead, and repeat. Arms bear the weight in the second step after the affected leg is moved forward 6 inches.
A client has been admitted to the hospital with a diagnosis of osteoporosis resulting in a compression fracture of the spine. The physician has ordered complete bed rest and has ordered a dietician consultation. Which of the following is the priority for the dietician to include in the nutritional counseling?
Show answer and rationale
Correct answer: C. Calcium intake should be 1500 mg daily
Calorie, protein, and fat intake if adequate for sustaining health are not a concern in osteoporosis. It is true that getting vitamins in the food is best; however, if additional vitamin D is required, a supplement is good if the client gets at least 15 minutes of sunlight per day. Calcium intake for women before menopause should be at least 1000 mg/day and after menopause should increase to at least 1500 mg/ day. In a client with osteoporosis at any age, adequate calcium intake is at least 1500 mg/day.
Which of the following would be the priority nursing action after being unable to palpate the client’s pedal pulse after an open reduction of a tibia fracture?
Show answer and rationale
Correct answer: B. Use a Doppler to check for the pedal pulse
To ensure that the circulation is intact when the pulse is not palpable, the nurse should use a Doppler. It is inappropriate to notify the physician without collecting all the appropriate data. Although checking the lower extremity pallor and measuring circumference will provide data of circulation, it does not ensure that a pedal pulse is present.
A client has received teaching on the use of a cane to assist with ambulation. Which of the following statements by the client would indicate to the nurse that further teaching is needed?
Show answer and rationale
Correct answer: B. "A walker would be more difficult to use than a cane."
The client should use the cane on the unaffected side. The elbow is held slightly flexed. There are different reasons to use a walker versus a cane; however, neither one is "better." Shoes must be worn. Never use socks alone. Socks may be optional to wear with the shoes.
During an exercise session, the nurse assists the client to dorsiflex and plantarflex the foot. The client asks what kind of exercise this is. Which of the following is the appropriate response by the nurse?
Show answer and rationale
Correct answer: D. Passive range of motion
Passive range-of-motion is exercise conducted with the assistance of another individual. Active range of motion is done by the client alone. Isometric exercise involves resistance, and isotonic exercise does not use resistance.
A client with systemic lupus erythematosus (SLE) is admitted to a nursing unit. Which of the following would indicate to the nurse that the client’s condition is deteriorating?
Show answer and rationale
Correct answer: D. Large amounts of protein in the urine
Protein in the urine indicates renal failure, and lupus nephritis is the number one cause of death in SLE. Serum sodium and potassium and glucose in the urine are not indicative of complications resulting from SLE. A serum sodium level of 145 mEq/L and a serum potassium level of 5.5 mEq/L are normal.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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